What is Social Capital? #illumedati

Hey everyone, it’s Medicine Mondays again and I’m going to talk about a concept that isn’t necessarily related to Medicine directly. However, I’m going to try to narrow down this concept into the medical field. Today we’re going to talk about “What is Social Capital?”

That makes it sound all very complex, so I’m going to simplify it into how I see it. I consider social capital as being very similar to “benefit of the doubt” at the lowest level, and then a form of professional trust at its highest level, within the scope of the medical field. In medicine, I will consider the “common good” to be “what is best for the patient”.

What do you mean?

Well, the best way to explain it is by example.

I’ve mentioned it before in passing, but I am a Caribbean Medical School graduate. It’s in my About page, and I’ve even written a follow-up post about it. I think one of the more difficult part of being a Caribbean Medical School graduate is that you don’t come in from day 1 with the “benefit of the doubt”. This is something that I think normal US Medical Students get. Other may argue this is not the case, however, experience, there is definitely a feeling that you “have to earn trust”.

This is kind of the first phase of “social capital” in my opinion. Also, this happens at every single step of training.

For example, as a first year preliminary medicine intern you develop social capital with your fellow co-interns, your senior residents, and your attendings. Within the first 6 weeks, and maybe even as early as the first month, everyone already knows who is “good” and “can be trusted”. This is most apparent when you are on night float.

There will always be someone who doesn’t sign out something important and then leaves before doing it intentionally. Only to make the night float intern “deal with it”.

Of course, the reverse is also true. There is always one nightfloat intern who will be signed out a bunch of stuff and then just not do it.

This is what I mean by the generating the benefit of the doubt. The inevitable question for the late intern will be “Who is my nightfloat intern?” and the night float intern’s question will be “Who is my late intern”. Intuitively, based on prior experiences the signout will be painful or painless depending on the answer.

Hmm… really?

Yes.

Now then, everyone makes mistakes. Being an intern is tough and sometimes you forget to sign out stuff, or something crazy happens overnight that you couldn’t foresee. However, there is a difference between forgetting to sign something out and neglecting to mention it.

The most worrisome sign out is “I have nothing to sign out”.

Really? You’re covering your whole floor, and the other 4 interns signed out at you at 5pm, and you’re signing out to be at 8pm and you have nothing to sign out? Seems suspect.

Here’s the difference.

Let’s say you’re a good intern and everyone knows you’re good. You take care of the problems quickly and efficiently. Nobody’s perfect, but you definitely take responsibility for your patients and for the signouts of your co-interns. You don’t “dump on the nightfloat”. Everyone knows you are like this. So you’ve built up this bank of “good will”. So even if for some reason you make a mistake and forgot to mention something, you’ll be forgiven. Your nightfloat intern and your senior resident will know there is no malicious intent.

Now let’s contrast contrast this with someone who is very well known to never take care of problems, with a habit of dumping things on their senior resident and co-residents to take care of. When it comes down to sign out, you can bet that the nightfloat intern is going to grill them and make sure they did their job. In some extreme cases, they may request that the senior resident to be present at the time of sign out. This is because their bank of “good will” is empty. In fact, any good will they may have is on loan from the bank.

However, it doesn’t stop there…

It happens every time you start somewhere new. Like in radiology residency, as a first year resident, you make daily deposits into the “bank of good will”. This includes being attentive during read out, doing a good job on your dictations, reading all the time, being punctual, etc. These deposits into the “bank of good will” actually have a form of “compound interest”. In other words, the deposits you make early on have a longer lasting impression than anything else and compounds. This harkens back to the “You never get a second chance to make a first impression.”

So then, as a 2nd year or a 3rd year, even when you make a mistake, you have enough in your “bank of good will” that you are given the benefit of the doubt.

This continues in fellowship, and also your first job.

The First Job

However, once you start your first job, you are in a whole new realm of social capital. I recommend you go back and read my post “Why Experience Matters” to better understand what I mean. After your first few months at your first job, you probably have sufficient “good will” in the social capital bank to get the benefit of the doubt. You have reached beyond the realm of “new employee” to being welcomed as “part of the team”.

It is only after this initial step that you can move forward with trust. This is not the same kind of trust in the personal sense, but in the professional sense, within the field of medicine. It’s difficult to understand this. However, within the medical field, even if you have two people with similar pedigrees, similar residency programs, and board certification, that is simply the baseline competency necessary.

I didn’t really understand this as a radiology resident. The reason for this is because from the first day of starting residency I was told that the Initial Board Certification Examination was the only thing that mattered. It wasn’t until much later that I understood that the Board Examination was the “bare minimum for competency”.

Professional Trust

Professional trust in the medical field comes from professional relationships. It comes from trading on your own name after gaining experience and sharpening your experience in the field. The best way to explain this is that I have a lot of friends in the medical field, especially in radiology, but we all have our own strengths and weaknesses. As a neuroradiologist, I think my friends/colleagues depend on me for my expertise in that particular area. However, even within neuroradiology there are relative strengths and weaknesses amongst neuroradiologists.

Outside of radiology, I have friends in various different fields of medicine who’s opinion I trust. It’s not just that I believe that they know everything, it’s more of that I trust them to tell me if they don’t know. They would then go on to direct me to someone who may know, or they would research it themselves and get back to me. This is all a part of professional trust.

Knowing your own limitations is just as important as your fund of knowledge.

In a smaller sphere, such as a smaller hospital system, the clinicians know who are the “go-to” people when they need help with a particular tough case. They also know which specialist “they would trust” to do their procedure or receive treatment from.

In other words, the doctors I would send my loved ones to have my highest level of professional respect. Now, like I said, that doesn’t mean they know everything, or have the highest pedigree, best board scores, or any other metric. It is simply a feeling of professional trust earned over a long period of time.

Is “Professional Trust” the same as “Reputation”?

No.

It may seem similar, but I think the term “reputation” is too superficial to describe the relationship I am talking about. When you talk about someone’s “reputation” it implies that you don’t know them on anything more than a superficial level. Professional trust goes way beyond that.

I think that if you ask individual doctors “who they would send their loved ones to” for problem X in subspecialty Y, then there would be a very short list that came to mind. The ones at the top of that short list have what I would consider “professional trust”.

TL;DR

Social capital has a broad definition, however, I’ve narrowed it into the scope of the medical field.

It starts with the bank of good will, leading to a benefit of the doubt, which strengthens, and ends in professional trust.

Professional trust is not the same as reputation.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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About Sensei

A young attending physician trying to navigate the mine field that is life after medical school...